Complete if applicable Beneficiary Designation

Wisconsin Department of Employee Trust Funds Box 7931 Complete if applicable Madison, WI 53707-7931. 1-877-533-5020 (toll free). Beneficiary Designation Beneficiary of: Fax: (608) 267-4549 Wis. Stat. (8) (a) and Alternate Payee of: Do not submit to your employer Refer to instructions on reverse Type or print in ink Your name First Middle I. Last Former/maiden Your Social Security number or ETF ID. Your address (Street number and street name) Your birth date (MM/DD/CCYY). / /. City State ZIP Code Your weekday telephone number (Include area code). ( ) - Any benefits payable by the Wisconsin Retirement System and Life Insurance program at my death shall be paid in EQUAL SHARES, unless otherwise specified, to the following primary Beneficiary (ies) who survive me.

If you are the owner of a Wisconsin Retirement System account from which a death benefit or life insurance benefit would be payable upon your death, you may file a

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  Death, Beneficiary, Designations, Payable, Beneficiary designation

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